- 1 -

Evaluation of Teaching Safety Procedure to Acquire Nurses,

Best Practice for Patient Receiving Blood Transfusion

Hanan Sobeih Sobeih1Asmaa Hamdy Mohamed

1and Marwa Moustafa Ragheb

2

1Medical Surgical Department., Faculty of Nursing-Ain Shams University

2Medical Surgical Department. Faculty of Nursing-Benha University

Abstract: A nurse by profession has opportunities to establish policies and

procedures, design nursing practices, and educate staff to help avoid blood

transfusion errors. Aim: To evaluate the effect of teaching safety procedure to

acquire nurses, best practice for patient receiving blood transfusion. Hypotheses:

The mean score of knowledge, practice and attitude post educational program of

nurses providing care for patients during blood transfusion procedure will be

higher than pre program. Design: A quasi experimental design was used to

conduct this study. Setting: This study was carried out at three critical units (ICU,

Hematological unit & Neurosurgery). Affiliated to Ain Shams University

Hospitals. Sample: A purposive sample included all nurses working at the

previously mentioned settings. Tools: A- Self administered interviewing

questionnaire involved five tools: 1- nurse's demographic data, 2- Blood

transfusion questionnaire: To assess the level of nurse's knowledge pre/post

program and follow-up period. 3 - Likert questionnaire : To assess level of nurse's

attitude towards safety of patient care pre/post program. 4- Nurse's barrier

questionnaire: To assess nurse's barriers toward her work pre/post program. 5-

Nurses' opinionair: To assess nurse's opinions toward the educational program at

the end of follow-up period .B - Blood transfusion observation checklist: To

assess the level of nurse's practices pre/post program and during follow up-period.

Results: That there were statistically significant differences among, studied nurses

in different settings of their work as regards satisfactory level of their knowledge

and competent level of their practice pre/post program and during follow up-

period. There were positive correlations found between total nurses' knowledge

and practices. There were changes recorded in the work barriers among the

studied nurses pre/post program. There were statistically significant differences as

regards nurses' attitude towards patient safety pre/post program. There were

differences recorded among the studied nurses' opinions as regards patient safety.

Conclusion: After conduction of the present study, results revealed nurses'

knowledge and practices about safety procedure of patient receiving blood

transfusion were increasing significantly after the educational program more than

before its implementation. Meanwhile, nurses' barriers as regards their work were

decreasing significantly after education program versus before its application. As

well, nurses' attitude was having statistically significant improvement post

educational program .A positive feedback was recorded as regards nurses'

opinions towards educational program at the end of follow up-period.

Recommendation: This study revealed inadequate practices that nurses and

hospitals should strive to change to provide a safe and more effective care that

would, hopefully, minimize the risks and maximize the benefits of blood

transfusion.

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Introduction:

Blood transfusion is a usual procedure in a hospital. Yet, it is

important and life-saving. It is an invasive procedure and can be fatal if

there is negligence. Every pint of blood received, there is always at least

one percent of risks from the transfusion and that the main cause of death

due to transfusion is acute hemolysis (51% of death). Most transfusion

errors (56%) happen in critical area (Yong et al., 2008)

Blood transfusion life-sustaining and life-saving treatment but it is not

without risk. Conditions that warrant blood transfusions range from acute

trauma to intra-operative blood loss, to compromised blood-cell production

secondary to disease or treatment. The nurse on the front line of patient

care must be adept at administering blood products safely and managing

adverse reactions quickly and with confidence. A lack of awareness of

good transfusion practice has been identified as a reason for poor

compliance ( Lynne et al.,2013).

The practice of blood transfusion is the transference of blood from the

circulation of one individual to another for practical therapeutic purposes.

Blood transfusion was performed with excessive complications in the

beginning of the 20th century. Today, these complications are limited by

increasing in the knowledge of healthcare workers in hospitals especially

the nursing staff and the knowledge of blood function. Error in transfusion

is one of the original causes of mortality, thus the awareness of this error is

important. Nowadays, blood and components are used more frequently in

surgical and non-surgical procedures (Lesley et al.,2007;and Richard,

2012).

In medical procedures, blood transfusion is important and needs

adequate skills. Security, safety and trust in transfusion are variables by

guidance about blood and components and depend on the expertise of

nursing staff. Blood transfusion is an elaborated procedure and performing

this procedure for a patient requires adequate skills and knowledge.

Healthcare workers in hospitals and other personnel who work with them

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are both of the original safe performers in transfusion procedures (Aslani

et al.,2010).

There is an urgent need of training programmers in critical units to

educate nurses on blood transfusion risks reduction, latest safety

guidelines, nurse interventions and decision making. Blood transfusion

saves lives and improves health, but millions of patients' need transfusions

do not have time access to have safe blood (WHO, 2008).

Blood transfusion is a safe process that saves lives and improves the

quality of life in a large range of clinical conditions. However, there are a

number of risks associated with transfusion as with any other clinical

intervention, right blood, right patient, and right time. Royal College of

Nursing guidance for improving transfusion practice sets out pragmatic

advice for nurses in the administration of red blood cells and plasma

components (fresh frozen plasma & cryoprecipitate and platelets), in acute

hospital care. The guidance is not wholly evidence-based but built on

recommendations to improve the safety of blood ordering and

administration from current national guidelines and serious hazards of

transfusion (Royal College of Nursing, 2005 and Adams et al., 2011).

.

The nurse handling the transfusion has a number of responsibilities to

ensure that the procedure is performed correctly and to ensure the

patient's safety and health. Before, during and after the transfusion, the

nurse will check the patient's temperature, pulse and blood pressure, and

will check for any signs of adverse reactions to the transfusion. While

reactions are rare, they are monitored. Symptoms for adverse reactions

include breathing problems, chills, fever, itching/hives, rash, nausea,

lower back pain, apprehensive feelings, tingling or numbness, heat, pain,

or swelling at the site where the IV is inserted. Patients are urged to keep

the nurse abreast of any symptoms they experience (Saillour et al., 2007

and Imperial College London, 2011).

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There is an urgent need of training program in hospital critical units to

have that educated nurses on blood transfusion risk reduction, latest safety

guidelines, nurse interventions and decision making. Nurses should be

aware of the recent advances and technological innovations in planning and

management of transfusion medicine (Sabrina &Justine, 2009 and

Fellowship Training Program, 2012).

Careful assessment of the risks and benefits of blood transfusion is

essential for a good patient outcome. In addition, it is essential that the

utilization of blood and blood products to be rationalized and they are

saved for critical situations (Asmaa et al.,2011).

Blood transfusion remarkably is a safe procedure, but like many other

clinical procedures, it is associated with clinical risks. These clinical risks

include adverse effects that occur due to error and suboptimal care during

the transfusion process. In the last 20 years, many studies have documented

errors at all stages in the transfusion process and there have been many

initiatives to minimize the occurrence of errors. Finding better ways to train

and support the staff directly involved in many steps of the transfusion

process remains essential (Frances,2011 and Rachel et al., 2011).

Significance of the study:

The safety and effectiveness of the transfusion process are dependent

on the knowledge and skills of nurses who perform the procedure. Poor

practice may result in avoidable complications that may threaten patients’

safety. Published work indicated that nurses’ practice varied across

contexts and highlighted that patients received suboptimal care and

incorrect transfusion culminated in death or morbidity (Hijji et al., 2010

and Michael etal.,2011).

Studies assessing best practice of safety procedure of blood transfusion

couldn't be traced in developing countries especially Egypt (Asmaa et

al.2011). Educationalal program in the current study for nurses in the

critical units about blood transfusion practice was the first trial in the

University Hospitals ( Ain shams & El-Demardash). this result was

reported by the researchers through Heads of Departments 2012.

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Aim of the study

The aim of the current study is to evaluate the effect of teaching safety

procedure to acquire nurses, best practice for patient receiving blood

transfusion

Research hypotheses

1- The mean score of knowledge and practice post educational

program of nurses providing care for patients during blood

transfusion procedure will be higher than pre program.

2- The mean score of nurses' attitude towards patient safety post

educational program will be higher than pre program.

Subjects and Methods

I-Technical Design:

It includes the study design, setting, subjects as well as tool for data

collection

Design: A quasi experimental design was used to conduct this study

Setting:

This study was carried out at three critical units (ICU, Hematology

&Neurosurgery) affiliated to El-Demerdash and Ain Shams University

Hospitals.

Sampling:

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1- Size: All nurses working at the previously mentioned settings were

recruited for the study. They were 40 nurses (18 nurses in ICU,12

nurses in hematological unit &10 in neurosurgery).

2- Inclusion criteria: All nurses, who did not attend of any educational

program about blood transfusion.

3- Sampling strategies: A purposive sample was used.

Tools of data collection:

A- Self administered interviewing questionnaire (studied nurses): involved five tools:

1- Bio-socio demographic data sheet :

It was used to collect data as regards studied nurses at different settings of

their work (ICU, Hematology& Neurosurgery) about; age, gender,

qualifications, and years of experience.

2- Blood transfusion questionnaire:

It was used to assess the level of nurses' knowledge pre/post program and

follow-up period. It was adopted from lynne et al.,(2013)and the Nursing

Blood Transfusion Reaction (2012).It was developed by the researchers

to suit the study. A questionnaire with 40 questions was divided into four

parts. The first part consisted of 11 questions related to blood components,

the second part consisted of 10 questions related to principles of blood

transfusion, and the third part involved 10 questions related to

complications of blood transfusion, while the fourth part consisted of 9

questions related to nursing intervention of blood transfusion reaction.

Each part was given 30 minutes to provide answers to these questions.

Satisfactory level of nurses knowledge scored ≥ 70% ,while unsatisfactory

level of nurse's knowledge scored <70% , the correct answer =2 and the

incorrect =zero.

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3 - Likert questionnaire patient safety:

It was used to assess level of nurse's attitude towards safety of patient

care pre/post program. It was adopted from Likert-scale-survey-best

practices, (2007) and Lynne et al., (2013) and modified by the

researchers according to the study aim. For the purpose of the following

10 questions, the nurse defined her attitude as regards safety care for the

patient, about willingness to report procedure errors, agree that patients

also play a role in preventing procedure errors, fear there will be negative

consequences associated with reporting procedure errors, cooperate with

other nursing staff to resolve patient safety issues, regularly report

procedure errors, feel comfortable reporting unsafe patient conditions to

the supervisor, believe most procedure errors are preventable, believe

their immediate supervisors are committed to improving patient safety,

hesitate to change practice habits to improve patient safety and are willing

to share information about procedure errors and what caused them.

Scoring was follows: an answer by strongly agree (3), agree (2), disagree

(1) or strongly disagree (0) and total score=30 marks.

4- Nurse's barrier questionnaire:

It was used to assess nurse's barriers toward their work during blood

transfusion procedure pre/post program. It was developed by the

researchers after reviewing of related literature ( Blood Transfusion

Policy ,2010) and also by participation of studied nurses. It involved

eight items as follows, absence of training program about procedure, lack

of experience, dangerousness procedure, fear of responsibility,

insufficient time of practice and change in workplace. It was answered by

scored "Yes /No"

5- Nurses' opinionair:

It was used to assess nurse's opinions toward the educational program at

the end of follow-up period after reviewing of other programs

(Fellowship Training Program, 2012) and guided by 3 experts from

medical surgical nursing. It included facilities available for training, key

learning objectives clearly defined, clear information available regarding

training needs of target group, resources available for teaching, and

quality of teaching material. It included nurses' opinions according three

responses "'good" ,"uncertain " and "poor".

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B - Blood transfusion observation checklist:

It was used to assess the level of nurse's practices about blood transfusion

pre/post program and during follow up-period .It was adopted from David

and Leuven, (2007) and (Tabiee &Nakhaei, 2010) and consisted of 3

phases; preparatory phase (8 items), procedure phase( 22 items), and blood

transfusion reaction phase(10 items).

Scoring system: Total items = 40 and scored by done correctly = 1 or not

done= zero. Evaluation of best nurse's practice considered to be competent

level was ≥80% , while incompetent level was <80%.

Content validity and reliability:

Validity test was done by three experts from Medical Surgical Nursing

specialty and others from hematologists. Alpha chronbach test was used

to measure the internal consistency of the tools. Reliability of used tools

or instruments, showed high reliability scores for the following tools:

Likert questionnaire patient safety, blood transfusion observation

checklist and nurse's opinionair having above the significant level

(R=0.8) and "test-re-test results' that all items of the barrier questionnaire

and knowledge questionnaire having acceptable reliability (alpha

coefficients ranged from ( 0.70 to 076).

II- Operational Design:

-Field work: After the official permission was taken from the Dean of the

Faculty of Nursing, the implementation phase for data collection started

as follows:

Data collection was carried out from May 2012 to January 2013.

The questionnaires were filled in by the nurses, while they were on work

place. The purpose of the study was explained before the distribution of

the questionnaire sheet and the sheets were answered within 30 minutes

then collected.

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The tools were administered to the study subjects three time (1)

Before the implementation of the program to have a baseline assessment

about nurses' level of knowledge to the conducted the program (2)

Immediately after the program implementation to assess the effect of

program (3) Three months later to assess the retention of knowledge

through comparing the result of pre, immediate post and follow up test of

the program to assess the effects of the educational program.

Concerning the observational checklist this sheet was filled in by

the researchers, while observing the studied nurses during applying

procedure related to care of patient receiving blood transplantation. The

time taken to complete this sheet was 15-20 minutes and according to the

availability of their time.

.

The construction of education program goes through four phases as

follows:

1. Assessment phase:

Assessment is the first phase in the program. Development of the

program was based on the context of the detected needs; this assessment

has shed light and given more insight about the professional needs of

nurses relevant to care of patient receiving blood transfusion. Preliminary

survey of nurses in different work places was achieved to help detecting

practical defects, deficiencies related to care of patient receiving blood

transfusion. Afterwards needs were classified to three main categories:

knowledge, practice, and attitude categories. Detected needs,

requirements and deficiencies were translated to aim and objectives of the

program.

2. Planning phase:

For planning the program as pointed out by (Teaching

Program (2013), the following was taken into consideration:

1. Participants: Sample characteristics defined the population actually

attending.

2. Method of assessing learner was identified.

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3. The scheduling of educational activities gave consideration to time

and location of sessions that best serve the learners.

4. Scheduling of courses provided evidence of different

distributions and locations convenient to the learners.

5-Detected needs were translated to aim.

6- Objectives were categorized and to specific objectives.

7-Contents of the program were selected on the base of identified

needs, objectives and educational background of nurses’ trainees.

8-Educational activities were selected to suit teaching small groups of

learners and available facilities. Selection of educational activities was

also made to facilitate a comprehension and integration of theory and

practice.

9- An illustrated guidance booklet about blood transfusion developed

by the researchers to be handled to each participant.

3- Implementation phase:

In the implementation phase, the program was applied three times

on six successive months as trainees had a part time for the program, and

night nurses were unable to participate in educational activities when the

first time the program was implemented and also it was very difficult to

take the whole number of the nurses at the same during their working

hours.

Teaching and learning activities were achieved in both the

classroom and the clinical area. It was aiming at providing trainees with

as much experiences as possible within the limitation of the research and

available resources of the study setting. Classroom activities consumed 2

hours/day in 3 days. Prerequisite level was defined according to

workplace, to evaluate nurses' level of knowledge practice and their

attitude in different critical units. Teaching methods in the classroom

were lectures, small group discussions, clinical conferences; real

situations in clinical area, problem solving, and brain storming. The

studied nurses were taught either individually or in groups. Teaching aids

utilized were work sheet, pen and paper, flip chart and board. The settings

were equipped and prepared to be used. The illustrated guidance booklet

was handled to each participant as a reference.

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4. Evaluation phase:

It was divided into two parts:

The first evaluation by the researchers

The evaluation phase was emphasized on estimating the effect of the

program on nurses' knowledge, practices and attitude through a written

test, observation checklist and rating scale. On one hand, evaluation of

the three domains was applied before and after the educational program in

order to identify differences, similarities and areas of improvement as

well as defects. On the other hand, the program was evaluated three

times, one before the program (pre-test), the second immediately after the

program (post-test) and the third one after three months of the program

implementation (follow-up). Education and training are fundamental to

every aspect of blood transfusion safety.

The second evaluation by trainees:

A. In this part the studied nurses evaluated the educational program at

the end of the following-up period through answering by "Yes/No as

regards the following items:

- Facilities available for training

- Key learning objectives clearly defined

- Clear information available regarding teaching needs of target group

- Resources available for teaching

- Quality of teaching material (learner feedback, handouts etc)

B. In this part the studied nurses' barriers pre/post program

percentage change were noticed .Decrease percentage as regards absence

of training program, lack of experience, dangerousness of the procedure,

fear of responsibility, insufficient time of practice except change of

workplace.

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III- Administrative Design:

Ethical consideration

After taking permission from Dean of Faculty of nursing to get

experience in the field blood transfusion, the researchers visited the

critical units of the mentioned hospital and got agreement from the

directors of these units to carry out the present study. This was after

clarifying and explaining the objectives of program of the study to ensure

maximum cooperation as well as to make arrangement for attendance of

the participants.

- Pilot study:

A pilot study was carried out on 4 nurses. It was done to test the

clarity and practicability of the tools. The results of the data obtained

from the pilot study helped in modifications on the tools, items were then

corrected or added as needed. Accordingly, modifications were done and

the final form was developed. Subjects who shared in the pilot study were

not included in the main study sample. The aim of this study was

explained to each nurse. Nurses were assured that information would be

confidential and used for their benefit and researching purpose only.

IV- Statistical Design:

Upon completion of data collection, variables included in each data

collection sheet were organized and tabulated and were coded before the

entry of computerized data, by using a program of statistical analysis, the

statistical package for social science (SPSS), including percentage, chi-

square and r-test. The observed differences and associations were

considered at p<0.05.

Limitation of the study:

1- It was very difficult to gather all nurses at the same time, so, the

program was applied three times on 6 successive months.

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Table (1): Socio- demographic data of studied nurses in different

setting of their work (n=40)

p-

value

X2

Neurosurgery

(n=10)

Hematology

(n=12)

ICU

(n=18)

Items

% No % No % No

>0.05

3.9

30.0

60.0

10.0

3

6

1

16.7

75.0

8.3

2

9

1

11.1

66.7

22.2

2

12

4

Age(in

years)

<25

25-<35

35+

28.8±5.3 29.6±4.4 31.4±5.3 Mean ±SD

>0.05

4.7

30.0

70.0

3

7

25

75

3

9

61.1

38.9

11

7

Gender Male

Female

>0.05

4.3

0.0

30.0

70.0

0

3

7

33.3

16.7

50.0

4

2

6

16.7

44.4

38.9

3

8

7

Qualification

Bachelor

Technical

institute

Diploma nurse

>0.05

5.2

80.0

10.0

0.0

10.0

8

1

0

1

66.7

8.3

8.3

16.7

8

1

1

2

16.7

44.4

5.6

33.3

3

8

1

6

Years of

experience

<3

3-<8

8-<13

13+

p>.05 ( Ins ign ificant)

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Table (2): Comparison among studied nurses in different setting as

regards level of knowledge of blood transfusion therapy pre/post

program and during follow-up period. (n=40)

p<0.001 ( h igh ly s ign ificant )

Satisfactory Level of Nurses Knowledge

Neurosurgery

(n=10)

Hematology

(n=12)

ICU

(n=18)

Items Follow-up Post- Pre- Follow-up Post- Pre- Follow

-up

Post- Pre-

No No No No No No No No No

7 9 0 12 12 2 12 15 3

Blood components(11

items)

X2=18.0 p<0.001 X

2=28.0 p<0.001 X

2=33.1 p<0.001

7 9

0

12 12 2

12

15

3

Principles of blood

transfusion

therapy(10 items)

18.0 X2= p<0.001 X

2= 28.0 p<0.001 X

2= 33.1 p<0.001

7 8 1

12

12 3 16 17 4 Complications of

blood transfusion

therapy (10 items)

X2=11.5 p<0.05

X2= 27.1 p<0.001

X2=32.8 p<0.001

8

10

0

12

12

3

12

15

2

Nursing intervention

of blood transfusion

reaction(9 item)

X

2=31.7 p<0.001 X

2=27.1 p<0.001 X

2=35.2 p<0.001

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Table (3): Comparison among studied nurses practices in different

setting as regards blood transfusion pre/post program and during

follow-up period. (n=40)

p<0.001 ( h igh ly s ign ificant )

Competent Level of Nurses Practices

Neurosurgery

(n=10)

Hematology

(n=12)

ICU

(n=18)

Items Follow-up Post- Pre- Follow-up Post- Pre- Follow

-up

Post- Pre-

No No No No No No No No No

9 10 0 12 12 1 12 18 2 Preparatory phase

(8 items)

X2=33.4 p<0.001

X2=29.7 p<0.001

X2=37.4 p<0.001

9

9

0

10

12

0

13

15

0

Procedure phase(22

items)

X2=43.1 p<0.001 X

2= 32.9 p<0.001 X

2= 31.8 p<0.001

9

10

0

12

12

3

14

16

2 Nursing intervention

of blood transfusion

phase(10 items)

X2=33.4 p<0.001 X

2= 27.1 p<0.001

X2=36.3 p<0.001

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Table (4) Correlations between total nurses' knowledge and total nurses'

practice pre/post program and at the end of follow up-period in different

settings of their work ( r- test )

**

**P <0.001 (h igh ly s ign ificant )

Total Nurses' Knowledge

Total Nurses'

Practices

Follow up- period

Post -program Pre -program

0.87**

0.99**

0.98**

0.95**

0.97**

0.98**

0.26

0.25

0.24

Pre-program

ICU

Hematology

Neurology

0.37

-

0.84

0.25

-

-

0.87**

0.97**

0.96**

Post-program

ICU

Hematology

Neurology

-

0.24

0.26

0.33

0.26

-

0.85**

0.91**

0.99**

Follow up- period

ICU

Hematology

Neurology

- 17 -

Table (5): Distribution among studied nurses towards their work

barriers about blood transfusion procedure pre/post program.

Number of Nurses Towards Work Barriers Pre/Post

Program

Items

Neurosurgery(n=10)

Hematology (n=12)

ICU (n=18)

Post -

program Pre-program Post -

program Pre-

program Post -

program

Pre-

program

% No % No % No % No % No % No

0.00 0 100 10 0.00 0 100 12 0.00 0 100 18 Absence of training

program about

procedure

30.0 3 70.0 7 8.3 1 33.3 4 0.00 0 16.7 3 Lack of experience 30.0 3 70.0 7 8.3 1 33.3 4 0.00 0 16.7 3 Dangerousness of

procedure 10.0 1 70.0 7 8.3 1 33.3 4 5.6 1 16.7 3 Fear of responsibility 10.0 1 70.0 7 8.3 1 33.3 4 5.6 1 16.7 3 Insufficient time of

practice 40.0 4 40 4 33.3 4 33.3 4 16.7 3 16.7 3 Change of workplace

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Table (6): Distribution among studied nurses in different setting

towards patient safety procedure pre/post program. n=(40)

Nurses' Attitude as Regards Patient Safety Procedure Pre/Post

Application of Program

Neurosurgery

(n=10)

Hematology

(n=12)

ICU (n=18)

Response Level

Post- Pre Post- Pre-

Post- Pre- Strongly agree(3)

Agree(2)

Disagree(1)

Strongly disagree(0)

No No No No No No

6

3

1

0

0

1

7

8

9

3

0

0

0

2

10

10

10

6

2

0

1

3

12

16

X2=18.2 p<0.001

X2=26.8 p<0.001

X2=16.9 p<0.001

- 19 -

Table (7) Studied nurses opinions as regards educational program at the

end of follow-up period (n=40).

Nurses Opinions' as Regards Educational Program at the

End of Follow-up Period N=40

Variables % No

25.5

50.0

25.5

10

20

10

Facilities available for

Training -Good

-Uncertain

-Poor

95.0

5.00

0.00

38

2

0

Key learning objectives

clearly defined -Good

- Uncertain

-Poor

87.5

12.5

0.00

35

5

0

Clear information available

regarding training needs of

target group

-Good

- Uncertain

-Poor

75.5

25.5

0.00

30

10

0

Resources available for

teaching -Good

- Uncertain

-Poor

62.5

37.5

0.00

25

15

0

Quality of teaching

materials

-Good

- Uncertain

-Poor

- 21 -

Results:

Table (1) reveals no statistically significant differences detected among

the studied nurses in different settings of their work (ICU, Hematology,&

Neurosurgery), as regards socio-demographic characteristics (age, gender,

qualification and years of experience) (p>0.05). In different settings, the

mean of their age was 31.4±5.3, 29.6±4.4 and 28.8±5.3 respectively.

Table(2) shows that there were highly statistically significant differences

among, studied nurses in different settings of their work as regards

satisfactory level of nurses' knowledge pre/post program and during

follow up-period towards blood components, principles, complication of

blood transfusion therapy and nursing intervention of blood transfusion

reaction (p<0.001) .However, there was statistically significant difference

in Neurosurgery Unit as regards complications of blood transfusion

therapy ( p<0.05).

Table(3) indicates that there were highly statistically significant

differences among studied nurses in different settings of their work as

regards competent level of nurses practice pre/post program and during

follow up-period towards preparatory phase, procedure phase of blood

transfusion therapy and nursing intervention of blood transfusion phase (

p<0.001).

Table (4) reveals no statistically significant correlations found between

total nurses' knowledge and practices in pre-program stage in different

settings, of their work, while there were highly positive correlations

among the three groups between pre/post program and during follow up-

period (p<0.001).

Table (5) indicates that there were changes recorded in the work barriers

among the studied nurses in ICU, Hematology and Neurosurgery units

pre/post program about blood transfusion procedure. Decreased

percentages were detected as regards absence of training program from

100% pre-program to 0.00% in different settings of their work ,as well,

lack of experience and dangerousness of procedure were decreased from

16.7% to 0.00%,from 33.3% to 8.3% and from 70% to 30% respectively.

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As regards fear of responsibilities and insufficient time of practice they

decreased from 16.7% to 5.6% from 33.3% to8.3% and from 70% to

10%respectively. However there were no recorded changes in their work

barriers as regards change of workplace in the same groups.

Table (6) shows that there were highly statistically significant differences

among the studied nurses in different settings of work as regards their

attitude towards patient safety during blood transfusion procedure

pre/post application of program (X2=

16.9,26.8&18.2 respectively at

p<0.001).

Table (7) reveals that there were differences recorded among the studied

nurses opinions at the end of follow up- period of the educational

program as regards patient safety during blood transfusion therapy. The

evaluation of their opinions for all items of the educational program

included the key learning objectives clearly defined, clear information

availability, resources available for teaching and quality of teaching

materials to be good (95%,87.5%,75.5%,&62.5% respectively ) .However

half of them (50%) their opinions were uncertain about the facilities

available for training program.

Discussion:

In the blood transfusion process, by becoming educated practitioners,

nurses can demonstrate their skill and competency in this field. This will

lead to increased compliance, in high risk areas, of the transfusion process,

such as patient identification procedures and record keeping. Further, it will

improve patient outcomes, and reduce procedure risk and error rates

(Royal College of Nursing, 2005).

In the present study, the socio-demographic characteristics of the

studied nurses revealed no statistically significant difference detected

among them as regards gender, qualification and years of experience. This

finding may increase chance of researchers of this study to assess the role

of educational program on level of knowledge, practices and attitude of

studied sample without interference of different variations or variables. As

well, may help the researchers to compare between these variables and

others in different study results.

- 22 -

As regards the satisfactory level of knowledge among the studied

nurses in different settings, of work pre-educational program they couldn't

get a passing level about blood components, principles, complications of

blood transfusion therapy and nursing intervention of blood transfusion

reaction, while post program, all of them were having a satisfactory level of

knowledge. Congruent with this study finding Hurt et al. (2012) showed

that the average knowledge of nurses can increase probable incidence of

risks related to blood transfusion and reduce safety procedure. Therefore,

the previous study recommends activation of a blood transfusion training

program in hospitals to control reports of blood transfusion and its

components as well as possible complications in wards, for nurses

emphasizing the weak points to increase their knowledge and continuously

supervise this task. The positive feedback of the educational program in the

current study on nurses' knowledge may help them in nursing intervention

phase during blood transfusion therapy.

In the same line, other studies supported the result of the current study,

as that of Michael et al.(2011) which reported that in their experimental

study on a stratified sample of 48 nurses showed that erroneous decisions

occurred in 18.2% of the 576 blood compatibility tests were performed at

the bedside which underscored the importance of continuing efforts to

update theoretical knowledge of nurses about this transfusion safety

procedure.

In the same issue, the studied nurses in different settings of their work

were having a competent level of practice post-educational program versus

pre-education program, where they couldn't get a passing level as regards

preparatory, procedure and nursing intervention of blood transfusion phase.

Best Nursing School (2012) reported that the nurse on the front line of

patient care must be adept at administering blood products safely and

managing adverse reactions with speed and confidence. A lack of

awareness of good transfusion practice has been identified as a reason for

poor compliance. In this point Hijji et al, (2010) added that the safety and

effectiveness of the transfusion process is dependent on the knowledge and

skills of nurses who perform the procedure. These findings may reflect the

positive effect of educational program to achieve main goal of this study,

and may help increase self confidence of studied nurses to make right

decisions during urgent situations such as blood transfusion reaction.

.

- 23 -

In the same line, there were no statistically significant differences between

nurses working in hematology unit and intensive care unit or neurosurgery

unit as regards their level of knowledge and practices pre- educational

program .This result is incongruent by Best Nursing School (2012), which

emphasized that most hospitals are looking for experienced hematology

nurses who can train the other nurses in an effective manner. Therefore, the

scope for hematology nurses with leadership skills is excellent, adding that

they can attain high positions in very little time by demonstrating skills in

quick decision making In additional by hematology nurses are also required

to educate the patients and their family members. The result of the current

study, indicating no differences among the studied nurses about their level

of knowledge and practices in dealing with blood transfusion, may be due

to the absence of specialty and change of nurses' workplace according to

critical units needs.

On the other hand, the results of this study revealed strong statistically

significant relations between level of nurses' knowledge and their practices

as regards blood transfusion therapy in all stages of procedure. In the

similar study Nursing Transfusion Reaction (2012) was in agreement

with these study findings and stated that insufficient knowledge about

blood transfusion was reflected in undesirable practice. Although he

emphasized that a positive correlation existed between the nurses'

knowledge and practice scores in his study. The result of this study may

indicate that the studied nurses were in need for an educational program to

overcome their deficiency of performance as regards blood transfusion

therapy.

Concerning assessment of the studied nurses' work barriers about blood

transfusion procedure pre/post program, percentage changes were noticed

.Decreased percentages related to absence of training program, lack of

experience, dangerousness of procedure, fear of responsibility,

insufficient time of practice were found except for change of workplace.

In this respect Lynne et al.(2013) identified that the lack of competence

may be an issue if over a prolonged period of time, a nurse makes

continuing errors or demonstrates poor practice which involves lack of

skill or knowledge, poor judgment and inability to work as part of a

health team. It might also identify a training need and set up a supervised

support program for the nurse to overcome on this problem. The

educational program might break down of most nurses' barriers except

- 24 -

change of their workplace as barrier due to hospital system. In their study

Bielefelt and Dewitt (2009) added that the shortage of nurses in many

medical settings can lead to lack of time. Without enough nurses on staff,

the amount of time available for each patient declines.

In the current study, the results indicated that there were statistically

significant differences among nurses in the different settings of work as

regards their attitude towards patient safety procedure pre and post

application of educational program. This study result is congruent with

that of Frances (2011), which reported that optimizing nursing staff's

time at the bedside is the key to better patient safety because the nurses

spend between 20 percent to 30 percent of their time in direct patient care

also the nurse and patient relationship is a pivotal component of any

patient safety program. The role of the nurse in patient safety presents

best practices to support the nurse as a patient safety advocate, so the

traditional educational programs do not prepare nurses for their evolving

role within the hospital setting. The result of this point in the current

study indicated that the studied nurses may achieve the main hypothesis

of this study.

In the same issue, the Fellowship Training Program (2012) added that

lack of competence may be an issue if over a prolonged period of time a

nurse makes continuing errors or demonstrates poor practice, which

involves, for example lack of skill or knowledge, poor judgment inability

to work as part of a team difficulty in communicating with colleagues or

lack of competence of their patient care, might also identify a training

need and set up a supervised support programmed for the nurse, but their

work may only show a temporary improvement which slips back when

the program is completed.

As regards the studied nurses' opinions in all items of educational

program, during follow up-period, they included; the key learning

objectives clearly defined, clear information available regarding training

needs of target group, resources available for teaching, and quality of

teaching materials were good, except half of them were uncertain about

the facilities available for training program. Effective training programs

answer the studied nurses' questions. The educational program on nursing

transfusion reaction carried out by Richard (2012) added that the design

of every training program must begin with learning objectives and

instructional designers need to create their programs with specific

- 25 -

objectives that their trainees must accomplish. These objectives must also

relate to actual skills that trainees need to be more successful at their jobs.

Trainers must also mention these objectives at the beginning of every

training module. The trainees will discover that they are more actively

engaged, and learn more when they clearly understand how training

relates to their jobs. The results of this issue, which may reflect the

success of the educational program, may overcome the weak points of

most educational program.

Conclusion:

After conduction of the present study, results revealed nurses'

knowledge and practices about safety procedure of patient receiving blood

transfusion were increasing significantly after the educational program

more than before its implementation. Meanwhile, nurses' barriers as

regards their work were decreasing significantly after education program

versus before its application and .As well, nurses' attitude was having

statistically significant improvement post educational program .A positive

feedback was recorded as regards nurses' opinions towards educational

program at the end of follow up-period.

Recommendation:

This study revealed inadequate practices that nurses and hospitals should

strive to change to provide a safer and more effective care that would,

hopefully, minimize the risks and maximize the benefits of blood

transfusion through the following:

1. All nurses must receive training program in blood transfusion.

2. Only nurses who have been trained and have specific qualifications

in blood transfusion method are allowed to practice it.

3. Nurse training curricula reflect the requirements of modern

transfusion method and other specialized fields of critical care units

such as hematological, intensive care and neurosurgical units.

4. Implementation and evaluation of continuous training programs is

carried out in order to improve the quality and safety of blood

transfusion.

- 26 -

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- 27 -

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